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sµ7 1 q ro /-0 SAN JOAQUII I COUNT�j ENI IRONM'ENTAL 11EA 1 I'�IZ'I I ENI ` MASTERFILE RECORD INFOMI ' FORIIZ P7 C- w E and New Facility �lewEH Program at ExistingFacility ❑Nc v EH program y EFcilif ID ) l'"--`J ro ratt2l2ecord�ID ��Sa�g �` Facility Addrm _� _ OJ`f 6 - --- �' .±� (please Check the appropriate desand pertinent information.) G� ✓� (��ii.."" FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Ilandlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending machines—Number of Units ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit—Mahe Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant ❑ Special Event —Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A hairy ❑ Grade 13 Dairy ❑Milk Dispenser—Number of Containers in Multi-Bead Unit COPA ❑ State Facility Surcharge(2399) IJAZARDOUS NVASTE PROGRAM(2200) ; ❑Iiaza.rdous Waste Generat.or. Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(221 g) ❑ Silver Only(2222) _ ❑ Appliance Recyelers(2217) Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(Cls) ❑Permit-lay-Rule Fixed Unit ❑Permit-Ey-Rule Household Hazardous Waste ® ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use US'T A and B Torras HOUSING PROGRAM(2400) ❑ Ilotel/IAlotel Number of Units ❑Jail or Exempt Institution Number of Units Ensployee Musing(2700) Use Egrploree I{ousigi~ Gab®r Camp Application Forms SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local MV Cleanup Site. ❑ NPI,fSEP Cleanup Site ❑ UIC Site ❑ Abandoned IIW Site ❑ Inou-NPL/SEP Cleanup Site ❑R�VQCB Cleanup Site ❑®Fater Quality Remediation Site RECREATIONAL.HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑Pool ❑ Spa ❑ Out of Senice Pool/Spa ❑Natural Bathing Area VECTOR r-ONTROL PROGRAM(4000) ❑ Poultry Fares Maximum number of birds 0 Kennel TATTOO,BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE RROGRAM(4200) ❑ Pumper Vehicle—Registration# License# Capacity Vehicle#, ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units SLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ,I&RVaste Tire Facility ❑ Compost Facility ❑ Process[Reeycle Facility ❑ CIA Landfill Site CI Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ FarnvRaach Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Ilauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----FJ 2- I O ❑ 11 -GO---❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PIKS 4642-003 T1rceApElka6Gn f-or-nr EMERGENCY NOTIFICATION FOR o Errs FACILITY ANDIOR PROGRAM CONTACT PERSON Day Ph Night Ph Przoc;Ii.AmEL.EMENT FEE ❑ Surcharge Fee ❑ Other FEE INSPECroR#�2C;. � PEP.riIIT VALID to ❑ Food Handler ❑ Chcck r7 [APIOUNT PAID Date INVOICE# ❑ Cash PEVIEVIEDBY AccoUNTIAGOFFICE Date �l��